Brazilian Ministry of Health
Health Surveillance Secretariat Department of STD, AIDS and Viral Hepatitis
Progress Report on the Brazilian Response to HIV/AIDS (2010-2011)
Brazil, 2012
Technical Data:
The institutional authorship of this document is of the Department of STD, AIDS and Viral Hepatitis (DDAHV), of the Health Surveillance Secretariat (HSS), Ministry of Health (MoH), Brazil.
General Coordination:
Dirceu Bartolomeu Greco, Director, DDAHV Eduardo Luiz Barbosa, Deputy Director, DDAHV Ruy Burgos Filho, Substitute Director, DDAHV
Organization:
Gerson Fernando Pereira, Ângela Pires Pinto and Giovanni Ravasi.
Report written by:
Sara Alves, Sergio D’Avila, Marcelo Araújo de Freitas, Cíntia Freitas, Ana Roberta Pati Pascom, Gerson Fernando Pereira, Ângela Pires Pinto, Francisco Viegas Neves da Silva, Giovanni Ravasi.
DDAHV/HSS/MoH Team:
Sara Alves, Marcela Rocha de Arruda, Eduardo Luiz Barbosa, Ivo Brito, Ruy Burgos, Gilvane Casimiro, Juliana Monteiro da Cruz, Sergio D’Avila, Marcelo Araújo de Freitas, Neide Fernandes, Noêmia Lima, Juliana Machado Givisiez, Rodrigo Zilli Haanwinckel, Ronaldo Hallal, Lilian Melo, Ana Roberta Pati Pascom, Silvano Barbosa de Oliveira, Giovanni Ravasi, Liliana Ribeiro, Karim Sakita, Lucas Seara.
Revised version 08 June 2012.
Index
Acronyms 04
Presentation 05
Chapter 1 – Introduction 08
Chapter 2 – The Brazilian Epidemiological Scenario 14
Chapter 3 – The National Response to HIV/AIDS 27
3.1. Prevention and Diagnosis 27
3.2. Care and Treatment 30
3.3. Human Rights 35
3.4. International Cooperation 36
Chapter 4 – Monitoring and Evaluation 43
Chapter 5 – Challenges and Perspectives 45
Bibliography consulted and sources 48
Appendices 52
Appendix I: Targets 1 to 5. Quantitative data relating to programme operation, the population’s knowledge and behaviour and the impact of AIDS
54
Appendix II: Target 6. Domestic and international AIDS expenditure by category and sources of funding
61
Appendix III: Target 7. National Commitments and Policy Instrument (NCPI) 66 National Commitments and Policy Instrument (NCPI) PART A administered to government officials.
66
National Commitments and Policy Instrument (NCPI) PART B1 administered to representatives from UN agencies.
91
National Commitments and Policy Instrument (NCPI) PART B.2 administered to Civil Society Organizations
108
Appendix IV: UNGASS Forum Letter 124
Acronyms
APAC – Autorização de Procedimentos Ambulatoriais de Alta Complexidade/Custo (Authorization for High Complexity/Cost Outpatient Procedures)
ARV – Antiretroviral
ARVT – Antiretroviral Therapy
BPO – Boletim de produção ambulatorial (Outpatient Production Bulletin)
CAMS – Comissão Nacional de Articulação com Movimentos Sociais (National Commission for Articulation with Social Movements)
CNAIDS – Comissão Nacional de DST, Aids e Hepatites Virais (National STD, AIDS and Viral Hepatitis Commission)
CTA – Centro de Testagem e Aconselhamento (Testing and Counselling Centre) DATASUS – National Health System Information Technology Department DDAHV - Department of STD, AIDS and Viral Hepatitis
HSS – Health Surveillance Secretariat - Ministry of Health IDU – Injecting Drug User
ILO – International Labour Organization MDG – Millennium Development Goals
MDS – Ministry of Social Development and Combat against Hunger MDU – Medication Dispensing Units
MEC – Ministry of Education MoH – Ministry of Health
MONITORAIDS – Department of STD, AIDS and Viral Hepatitis Indicator Monitoring System MRG – Médicos de Referência em Genotipagem (Genotyping Reference Doctors)
MSM – Men who have Sex with Men
NCPI – National Commitments and Policy Instrument
LGBT – Lesbians, Gay men, Bisexuals, Transvestites and Transsexuals NGO – Non-Governmental Organization
NHS – National Health System
NOAS – Norma Operacional da Assistência à Saúde (Healthcare Operational Norm) PAHO – Pan American Health Organization
PLWHA – People Living With HIV and AIDS
QUALIAIDS – Evaluation and Monitoring of the Quality of AIDS NHS Outpatient Care RDS – Respondent Driven Sampling
SAE – Serviço de Atendimento Especializado (Specialized Care Service)
SEDH – Human Rights Secretariat of the Office of the President of the Republic SES – State Health Department
SICLOM – Sistema de Controle Logístico de Medicamentos (Medication Logistics Control System) SIM – Sistema de Informação de Mortalidade (Mortality Information System)
SINAN – Sistema de Informação de Agravos de Notificação (Communicable Diseases Information System)
SISCEL – Sistema de Controle de Exames Laboratoriais (Laboratory Tests Control System) SMS – Municipal Health Department
SPM – Women’s Policy Secretariat STD – Sexually Transmitted Diseases
UNAIDS – Joint United Nations Programme on HIV and AIDS UNFPA – United Nations Population Fund
UNGASS – United Nations General Assembly Special Session on HIV/AIDS UNICEF – United Nations Children’s Fund
UNITAID – International Facility for the Purchase of Drugs against AIDS, Tuberculosis and Malaria
WHO – World Health Organization
Presentation
This progress report presents relevant indicators and information on the Brazilian response to AIDS during the period 2010/2011, based on the guidelines of the Joint United Nations Programme on HIV and AIDS - UNAIDS (“Global AIDS Response Progress Reporting 2012. Guidelines: construction of core indicators for monitoring the 2011 Political Declaration on HIV/Aids”)1.
Ten years after the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), progress on the global response to AIDS was discussed again in June 2011 in New York, at the United Nations General Assembly High Level Meeting on AIDS. The result of the meeting was a new Political Declaration of commitment by the Member States, including Brazil, and the definition of six new targets to be achieved by 2015:
1. Halve sexual transmission of HIV;
2. Reduce transmission of HIV among people who inject drugs by 50%;
3. Ensure that no children are born with HIV;
4. Increase access to antiretroviral therapy to get 15 million people on life saving Treatment;
5. Reduce tuberculosis (TB) deaths in people living with HIV by 50%;
6. Close the global resource gap for AIDS and work towards increasing funding to between US$ 22 and US$ 24 billion per year and recognized that investments in the AIDS response is a shared responsibility.
The Political Declaration also clearly draws attention to the urgent need to enhance access to health services by vulnerable populations, such as men who have sex with men (MSM), people who use drugs (IDU) and sex workers, as well as the need to eliminate gender- based iniquities and abuse.
Following on from the previous reports, this document portrays the current situation of the epidemic in Brazil and the response to it in terms of policies, programmes and strategies adopted by the government in partnership with other stakeholders. It is important to emphasize that the Brazilian response to the AIDS epidemic is embedded in the National
1 UNAIDS. Global AIDS Response progress reporting: monitoring the 2011 political declaration on HIV/AIDS: guidelines on construction of core indicators: 2012 reporting. 2011. Document available at:
http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/globalaidsprogressreport/
Health System (NHS), the principles of which are universality, equity and integrality, as well as regarding health as a fundamental human right.
The process of preparing this document was assisted by the contributions of the National STD, AIDS and Viral Hepatitis Commission and the Commission for Articulation with Social Movements, both of which are advisory bodies to the Ministry of Health’s Department of STD, AIDS and Viral Hepatitis; the United Nations Agencies, under UNAIDS coordination; and state-level managers of the HIV/AIDS policy. The document also presents the discussions that took place in the UNGASS Forum, a civil society initiative supported by the government.
Chapter 1 provides a brief introduction to the context of the Brazilian response to HIV/AIDS, a description of how the progress report has been prepared, as well as providing summary tables of the indicators.
Chapter 2 presents the profile of the AIDS epidemic in Brazil, including updated HIV/AIDS epidemiological surveillance information, sentinel surveillance studies with parturient women and armed forces conscripts, as well as special studies with vulnerable populations: sex workers, men who have sex with men and people who use drugs.
Chapter 3 describes the Brazilian response from the political and programmatic perspective. Its main aim is to discuss the core elements of the Brazilian response to AIDS embedded in the National Health System. The chapter details the response in terms of prevention, diagnosis, care, support and treatment, human rights and international cooperation.
Chapter 4 presents the monitoring and evaluation system adopted and implanted by Brazil.
Chapter 5 presents the current challenges and perspectives of the response to the epidemic in Brazil.
The narrative part of the report ends with the bibliography and the list of websites consulted. The appendices to the report contain the progress indicators divided into three sections:
- Appendix I: Targets 1 to 5. Quantitative data relating to programme operation, the population’s knowledge and behaviour and the impact of AIDS;
- Appendix II: Target 6. Domestic and international AIDS spending by categories and financing sources; and
- Appendix III: Target 7. National Commitments and Policy Instrument (NCPI) which, based on three forms, presents the perspectives of government officials, international agencies and Brazilian civil society.
- Appendix IV: UNGASS Forum letter (2011).
Chapter 1 Introduction
Brazil is a federative republic comprised of 26 states and a federal district, divided into 5,565 municipalities. The country has an area of 8,511,925 square kilometres. This is equivalent to 47% of the South American territory and represents the planet’s fifth largest territorial area, as well as having the world’s fifth largest population. Brazil’s population, according the 2010 Demographic Census performed by the Brazilian Institute of Geography and Statistics (IBGE), had reached 190,755,799 inhabitants, with 84.4% of the population being defined as urban. In 2008 the total rate of illiteracy was 11.48%, whilst among the young (15- 19 years old) it was 1.74%.
With regard to health, the National Health System (NHS), created in Brazil with effect from the promulgation of the new Federal Constitution in 1988, made access to health a right of the entire population and a duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other complaints, as well as being aimed at achieving universal and equal access to actions and services for health promotion, protection and recovery (Article 196 of the Federal Constitution). Its basic principles are universality, equity and integrality. The NHS is organized in a decentralized manner involving articulation between the three levels of the Federation: Union, States and Municipalities.
In relation to AIDS, 30 years into the epidemic it is stabilized and concentrated in certain vulnerable population sub-groups. According to the most recent Epidemiological Bulletin (base year 2010), there were 608,230 cumulative AIDS cases between 1980 and June 2011, of which 397,662 (65.4%) were male cases and 210,538 (34.6%) were female cases.
These cases were reported on the Communicable Diseases Information System (Sistema de Informação de Agravos de Notificação - SINAN), the Mortality Information System (Sistema de Informação de Mortalidade - SIM) and the Laboratory Tests Control System / Medication Logistics Control System (Sistema de Controle de Exames Laboratoriais - SISCEL) / Sistema de Controle Logístico de Medicamentos - SICLOM).
The rate of HIV infection prevalence in the population aged 15 to 49 has been stable at 0.6% since 2004, being 0.4% in females and 0.8% in males. With regard to more vulnerable population groups aged over 18, studies conducted in 10 Brazilian municipalities between 2008 and 2009 estimated HIV prevalence rates of 5.9% in IDU, 10.5% in MSM and 4.9% in female sex workers.
The Brazilian response to the AIDS epidemic is based on the principle that all people have the right to health. This human rights-based principle is guaranteed by the NHS and counts on the permanent mobilization of civil society for its effective implantation, thus enabling the structuring of a programme to provide universal access to prevention, treatment and care, this being the most important characteristic of the Brazilian response to AIDS. An aspect of this response is that for it to be efficient, long-lasting and capable of maintaining and innovating itself, it must contemplate healthcare in all its dimensions within a well-structured public health system.
Given that 2010-2011 is the period covered by this report on the commitments taken on by Brazil with regard to HIV/AIDS, it has been compiled from data collected from a variety of different areas. The Ministry of Health’s Department of STD, AIDS and Viral Hepatitis coordinated the preparation of this Progress Report, which received contributions from the National STD and AIDS Commission, the Commission for Articulation with Social Movements, United Nations Agencies (coordinated via UNAIDS) and state-level HIV/AIDS policy managers.
In addition, the social movement has a specific forum for discussing the aforementioned decisions established at the 2011 United Nations General Assembly High Level Meeting on AIDS.
The process of preparing the indicators, the results of which are shown in Appendices 1-3, was undertaken by the Department of STD, AIDS and Viral Hepatitis. With regard to the indicators relating to the first five strategic targets of the 2011 Political Declaration (Appendix 1; Summary tables 1-5) several different information systems managed by the Department of STD, AIDS and Viral Hepatitis, the Health Surveillance Secretariat and the Ministry of Health were consulted, as were data from behaviour and epidemiological surveillance studies. The Block 6 indicators (Appendix 2; Summary table 6) on expenditure were compiled using the National AIDS Spending Analysis (Medição do Gasto em Aids - MEGAS) method, based on 2009 and 2010 spending.
With regard to the National Commitments and Policy Instrument (NCPI) (Appendix 3), part A was applied by the Department of STD, AIDS and Viral Hepatitis with contributions from the state-level STD, AIDS and Viral Hepatitis Programmes, which are responsible for coordinating the AIDS response in the Brazilian states. Part B of the NCPI has been divided into two, in the same way as the previous report: B1, coordinated by UNAIDS and answered jointly by the United Nations Agencies in Brazil; B2, coordinated by the Commission for Articulation with Social Movements.
Finally, the descriptive report was prepared with the participation of all the Programmes, the Monitoring and Evaluation Unit, the International Cooperation Support Unit, with overall coordination by the Directorate of the Ministry of Health’s Department of STD, AIDS and Viral Hepatitis.
Summary Table 1. Target 1 Indicators: Halve sexual transmission of HIV by 2015.
Indicat or No.
Sub-indicator Total
%
Male % Female %
Percentage (%) of respondents aged 15-24 who gave the correct answer to all five questions.
51.7 52.97 27.05
Percentage (%) of respondents aged 15-24 who answered question 1 correctly: "Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners?"
75.61 79.34 71.82
Percentage (%) of respondents aged 15-24 who answered question 2 correctly: "Can a person reduce the risk of getting HIV by using a condom every time they have sex?"
96.98 97.51 96.38
Percentage (%) of respondents aged 15-24 who answered question 3 correctly: "Can a healthy-looking person have HIV"?
92.6 92.6 92.59
Percentage (%) of respondents aged 15-24 who answered question 4 correctly: "Can a person get HIV from mosquito bites?" (or country- specific question).
96.1 95.82 96.3
1.1
Percentage (%) of respondents aged 15-24 who answered question 5 correctly: "Can a person get HIV by sharing food with someone who is infected?" (or country-specific question).
75.01 72.43 77.54
1.2 Percentage (%) of young women and men aged 15-24 who have had sexual intercourse before the age of 15.
35.46 40.85 29.45
1.5 Percentage (%) of women and men aged 15-49 who received an HIV test in the past 12 months and know their results.
14.18 10.72 17.62
1.6 Percentage (%) of young women aged 15-24 who are living with HIV. - - 0.26
Percentage (%) of female sex workers who replied "yes" to both questions.
- - 46.81
Percentage (%) of female sex workers who replied "Yes" to question 1:
"Do you know where you can go if you wish to receive an HIV test?"
- - 56.76
1.7
Percentage (%) of female sex workers who replied "Yes" to question 2:
"In the last 12 months, have you received condoms?"
- - 77.09
1.8 Percentage (%) of sex workers (women and men) reporting the use of a condom with their most recent client.
- - 90.09
1.9 Percentage (%) of sex workers who received an HIV test in the past 12 months and know their results.
- - 17.52
1.10 Percentage (%) of sex workers who are living with HIV. - - 4.91
Percentage (%) of MSM who replied "Yes" to both questions - 38.74 - Percentage (%) of MSM who replied "Yes" to question 1: " Do you know
where you can go if you wish to receive an HIV test?"
- 40.47 -
1.11
Percentage (%) of MSM who replied "Yes" to question 2: “In the last 12 months, have you received condoms?”
- 70.16 -
1.12 Percentage (%) of men reporting the use of a condom the last time they had sex with a male partner.
- 59.73 -
1.13 Percentage (%) of MSM who received an HIV test in the past 12 months and know their results.
- 19.11 -
1.14 Percentage (%) of MSM who are living with HIV. - 10.51 -
Indicat or No.
Sub-indicator Total
%
Male % Female %
1.15
Percentage (%) of general health services offering HIV counselling and testing services.
0.8 - -
Percentage (%) of women accessing antenatal heath care services tested for syphilis at their first antenatal appointment.
- - 86.47
Percentage (%) of women accessing antenatal heath care services who received a positive syphilis test result.
- - 1.1
Percentage (%) of women accessing antenatal heath care services who received a positive syphilis test result and received treatment.
- - 80.55
1.17
Percentage (%) of sex workers with active syphilis. - - 2.5
Summary Table 2. Target 2 Indicators. Reduce transmission of HIV among people who inject drugs by 50% by 2015
Indicator No.
Sub-indicator Total No. Total %
2.2 Percentage (%) of people who inject drugs reporting the use of a condom the last time they had sexual intercourse.
- 40.67
2.3 Percentage (%) of people who inject drugs reporting the use of sterile injecting equipment the last time they injected.
- 54.31
2.4 Percentage (%) of people who inject drugs who received an HIV test in the past 12 months and know their results.
- 15.0
2.5 Percentage (%) of people who inject drugs who are living with HIV. - 5.92 2.6 Estimated number of opiate users (injecting and non-injecting). 472,700 -
Summary Table 3. Target 3 Indicators. Ensure that no children are born with HIV by 2015 (and substantially reduce AIDS-related maternal deaths).
Indicator No. Sub-indicator Total No. Total %
3.1 Percentage (%) of HIV-positive pregnant women who receive antiretrovirals to reduce the risk of mother-to-child transmission.
- 50.23
3.2 Percentage (%) of infants born to HIV-positive women receiving a virological test for HIV within 2 months of birth.
- 35.24
3.3 Percentage (%) of child HIV infections from HIV-positive women delivering in the last 12 months.
- 6.8
3.6 Percentage (%) of HIV-positive pregnant women assessed as to their eligibility for ARVT, either by their clinical stage or CD4 count.
- 37
3.7 Percentage (%) of infants born to HIV-positive women (children exposed to HIV) who received antiretroviral prophylaxis to reduce the risk of early mother-to-child transmission in the first six weeks of life (i.e. early postpartum transmission at around 6 weeks of age).
- 61.5
3.11 Number of pregnant women who had at least one antenatal consultation during the reporting period.
2,795,278 93.3
Number of health services offering antenatal care. 48,741 -
Number of health services offering antenatal care which also perform CD4 counts at the same place or have a system for the collection and transportation of blood samples for CD4 counts in HIV-positive pregnant women.
250 -
3.12
Number of health services offering paediatric ARVT. 451
Percentage (%) of health services offering virological tests (e.g. PCR) to diagnose HIV in newborn babies at the same health service or using drops of dry blood.
- 26.2
Summary Table 4. Target 4 Indicators. Increase access to antiretroviral therapy to get 15 million people on life saving treatment by 2015.
Indicator No. Sub-indicator Total No. Total %
4.1 Percentage (%) of eligible adults and children currently receiving antiretroviral therapy.
215,676 72*
4.2a Percentage (%) of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy (out of those starting therapy in 2010).
- 93.03
4.2b Percentage (%) of adults and children with HIV still alive and on treatment 24 months after initiation of antiretroviral therapy (out of those starting therapy in 2009).
- 75.6
4.2.c Percentage (%) of adults and children with HIV still alive and on treatment 60 months after initiation of antiretroviral therapy (out of those starting therapy in 2006).
- 74.3
4.3 Number of health services offering antiretroviral therapy (ARVT) (i.e. prescribe and/or provide clinical monitoring).
737 -
* Of the estimated 540,000 PLWHA, 215,000 are on treatment and another 100,000 on follow up but yet not eligible to treatment. Of the remaining 225,000 not yet diagnosed, it is estimated that 33% of them have CD4 below 350 and should be on treatment. Thus, 72% of the 299,250 eligible are on treatment.
Summary Table 5. Target 5 Indicators. Reduce tuberculosis (TB) deaths in people living with HIV by 50% by 2015.
Indicator No. Sub-indicator Total No. Total %
Note: in the report none of the target 5 indicators have been filled in.
Summary Table 5: Expenditure distribution by category, Brazil, 2009 and 2010.
Category 2009 % 2010 %
Prevention 265,170,632 20.2 264,700,268 19.9
Care and treatment 871,399,850 66.3 933,417,719 70.2
Programme management and
administration strengthening 104,205,312 7.9 72,202,450 5.4 Incentives for human resources 2,065,958 0.2 3,801,414 0.3 Social protection and social services 31,778,810 2.4 37,097,417 2.8 Enabling environment and
community development 35,253,348 2.7 16,559,990 1.2
Research 3,823,820 0.3 1,017,343 0.1
TOTAL 1,313,697,730 100.0 1,328,796,601 100.0
DDAHV/HSS/MoH, 2012.
Chapter 2 The Brazilian Epidemiological Scenario
The AIDS epidemic is stable and concentrated in certain vulnerable population sub- groups. The national HIV infection prevalence rate in this age group has been stable at approximately 0.6% since 2004, being 0.4% in females and 0.8% in males. These estimates are obtained through the Parturient Women Sentinel Study, which also estimates syphilis prevalence (1.6%), as well as evaluating the quality of healthcare during the antenatal period and childbirth throughout the country’s entire public health network. It is important to note that the population of parturient women has been monitored since the 1990s because its HIV prevalence rate is similar to that of the general female population. Brazil conducted a new parturient sentinel study in 2011, the data of which will be published in 2012. In the case of young women aged 15-24, the HIV prevalence rate estimated in 2006 was similar to the rate of approximately 0.26 found in 2004(Szwarcwald CL, 2008).
Brazil also periodically conducts surveys with Armed Forces Conscripts, these being young men aged 17-20 enlisting for compulsory military service. This population is quite heterogeneous as far as its socio-economic characteristics are concerned and is representative of young men in this age group in Brazil. The principle objectives of the survey are to identify HIV and syphilis prevalence among these young men and their behaviour in terms of the risk of HIV and other STD transmission. In 2007 the HIV prevalence rate in this population was estimated at 0.12%whilst the syphilis prevalence rate was 0.5% (Szwarcwald CL, 2005, 2007).
With regard to population subgroups most at risk, studies conducted in ten Brazilian municipalities (Manaus, Recife, Salvador, Belo Horizonte, Rio de Janeiro, Santos, Curitiba, Itajaí, Campo Grande and Brasília) between 2008 and 2009 estimated HIV prevalence rates of 5.9% among drug users (Bastos FI, 2009), 10.5% among men who have sex with men (Kerr L, 2009) and 5.1% among female sex workers (Szwarcwald CL, 2009).
Regarding AIDS in Brazil, between 1980 and June 2011, 608,230 AIDS cases were reported on the SINAN, SIM, SISCEL and SICLOM systems, with 56.4% in the South-East Region;
20.2% in the Southern Region; 12.9% in the North-East Region; 5.8% in the Midwest Region;
and 4.7% in the Northern Region (Graph 1).
Graph 1.
Graph 2.
In 2010, 34,218 AIDS cases were reported on the SINAN, SIM and SISCEL/SICLOM systems. 14,142 (41.3%) of these occurred in the South-East Region; 7,888 (23.1%) in the Southern Region; 6,702 (19.6%) in the North-East Region; 3,274 (9.6%) in the Northern Region;
and 2,211 (6.5%) in the Midwest Region. With regard to the percentage distribution of AIDS cases reported on the SINAN, SIM and SISCEL/SICLOM systems between 1998 and 2010, a reduction of 34.7% can be seen in the proportion of cases in the South-East Region (from 63.31% in 1998 to 41.33% in 2010), whereas the proportion of cases in the other regions increased in the same period (Graph 2).
In terms of absolute numbers in the country’s regions, the highest number of cases is found in the Northern Region state of Pará (12,532); in the North-East it is found in the state of Bahia (19,290); in the South-East Region it is found in the state of São Paulo (207,077); in the Southern Region it is found in the state of Rio Grande do Sul (60,512) and in the Midwest Region the highest number of cases is found in the state of Goiás (12,588).
With regard to the incidence of AIDS cases reported on the SINAN, SIM and SISCEL/SICLOM systems, a rate of 17.9/100,000 can be seen in the year 2010, indicating stabilization over the last 12 years. The incidence rates in the country’s regions in the year 2010 were: 28.8/100,000 inhabitants in the Southern Region; 20.6 in the Northern Region;
17.6 in the South-East Region; 15.7 in the Midwest Region; and 12.6 in the North-East Region (Graph 3).
Graph 3.
With regard to the country’s five regions during the period 1998 to 2010, a decrease of 30.9% in the incidence rate can be seen in the South-East Region, which accounts for 56.4% of national cumulative cases, whilst there is an increase in the other regions. In 2010, eight of the country’s 27 Federative Units had incidence rates above the national average (17.9/100,000 inhab.): Amazonas (30.9), Roraima (35.7) and Pará (19.5) in the Northern Region; Espírito Santo (20.4) and Rio de Janeiro (28.2) in the South-East Region, and all the states in the Southern Region. Analysis of the ranking of the Federative Units over time shows that since the year 2000 the state of Rio Grande do Sul has had the highest AIDS case incidence rate.
Between 1980 and June 2011, 397,662 (65.4%) male AIDS cases and 210,538 (34.6%) female AIDS cases were reported on the SINAN, SIM and SISCEL/SICLOM systems. In 1998 the incidence rate was 25.0/100,000 inhabitants in men and 12.6 in women, whereas in 2010 the rate in men was 22.9/100,000 inhabitants and 13.2 in women. The sex ratio, which was 40 men to 1 woman in 1983, was 1.7 men to 1 woman in 2010 (Graphs 4 and 5).
Graph 4.
Graph 5.
In 2010, the 35-39 age group has the highest incidence rate in the country (38.1 cases/100,000 inhab.). Between 1998 and 2010 an increase in AIDS cases can be seen in the 05-12, 50-59 and 60 and over age groups (Graph 6).
Graph 6.
The AIDS incidence indicator in children aged under five is important because it is a proxy indicator which is used to monitor progress with the control of mother-to-child HIV transmission. Targets for the reduction of this form of transmission have been agreed with the state and municipal health authorities.2
2 Mendes Pereira GF, Caruso da Cunha AR, Rocha Moreira MB et al. Perspectivas para o controle da transmissão vertical do HIV no Brasil [Prospects for control of HIV vertical transmission in Brazil]. Saúde Brasil 2010. An analysis of health situation and of selected evidence of the impact of the health surveillance actions.
14,127 AIDS cases were reported in children aged under five between 1980 and June 2011. In terms of the country’s regions in the same period, 7,383 (52.3%) cases were diagnosed in the South-East Region, 3.499 (24.8%) in the Southern Region, 1,750 (12.4%) in the North-East Region, 771 (5.4%) in the Northern Region, and 723 (5.1%) in the Midwest Region.
482 cases were reported in 2010. This corresponds to an incidence rate of 3.5/100,000 inhabitants. In 1998 there were 947 cases and the incidence rate was 5.9/100,000 inhabitants.
In the period between 1998 and 2010 there was a 49.1% reduction in the absolute number of cases and a 40.7% reduction in the incidence rate. Nevertheless, in the same period an increase in the incidence rate can be seen in this age group in the North and North-East regions, whereas there is a significant reduction in the South-East, South and Midwest regions (Graph 7).
Graph 7.
When considering the Federative Units between 1998 and 2010, there was an increase in the AIDS incidence rate in children aged under five in all the Northern Region states, with the exception of the state of Acre. The same occurred in all the North-East region states and also in the state of Espírito Santo in the South-East Region. In 2010, the states of Amazonas (8.,1/100,000 inhab.), Roraima (4.2), Pará (5.4), Rio Grande do Norte (4.7), Paraíba (5.2), Alagoas (5.1), Espírito Santo (10.2), Rio de Janeiro (5.8) and Rio Grande do Sul (7.8) had incidence rates above the national average (3.5).
With regard to AIDS cases reported on the SINAN system in children aged under 13 by exposure category, out of the total of 15,775 reported cases between 1980 and June 2011, 13,540 (85,8%) fell into the category of exposure owing to mother-to-child transmission.
In the 13 and over age group, 15,026 male AIDS cases were reported on the SINAN system in 2010. Of these, 22.0% are homosexual, 7.7% bisexual, 42.4% heterosexual, 5.0% IDU, 0.6% mother-to-child transmission and 22.1% are unknown. With regard to the 8,210 female cases reported on the SINAN system in 2010, 83.1% are heterosexual, 2.2% IDU, 0.9% mother- to-child transmission, whilst the exposure category of 13.8% of these cases is unknown (Graph 8).
Graph 8.
Graph 9.
Analysis by race/colour in 2010 reveals that 49.6% of cases reported on the SINAN system are white, 10.8% are black, 0.5% are yellow, 38.6% are brown, 0.4% are indigenous and 8.1% are unknown. With regard to gender, in 2010, 51.2% of male cases were white, 9.8%
were black, 0.5% was yellow, 38.2% were brown, 0.3% was indigenous and 8.2% were unknown. 46.7% of female cases were white, 12.7% were black, 0.7% was yellow, 39.4% were brown, 0.5% was indigenous and 7.8% were unknown with regard to race/colour (Graph 9).
In terms of education, in 2010, 14.2% of reported cases on the SINAN system had studied for up to four years or less at school (5.9% had completed four years); 27.4% had studied for between five and eight years at school (9,8% had completed eight years); 20.1%
had studied at sixth form level (13.3% had completed sixth form); and 8.2% had studied at higher education level (5.3% had completed higher education); 2.4% were illiterate; no information was available for 26.5% of cases.
Still with regard to education, in 2010 it can be seen that among females the proportion of AIDS cases in the literate and those who studied at middle school, whether they finished middle school or not, is higher than among males. The proportion of AIDS cases
among males who completed sixth form education or who studied at higher education level, whether they completed it or not, is higher than among females.
There were 241,469 deaths attributed primarily to AIDS in Brazil between 1980 and 2010. Of these, 155,088 (64.2%) occurred in the South-East Region, 40,414 (16.7%) in the Southern Region, 26,172 (10.8%) in the North-East Region, 11,639 (4.8%) in the Midwest Region, and 8,154 (3.4%) in the Northern Region. There were 11,965 deaths in Brazil in 2010, of which 5,687 (47.5%) occurred in the South-East Region, 2,574 (21.5%) in the Southern Region, 2,020 (16.9%) in the North-East Region, 923 (7.7%) in the Northern Region, and 761 (6.4%) in the Midwest Region.
The gross AIDS mortality coefficient in Brazil in 2010 was 6.3/100,000 inhabitants.
Taking the Brazilian population in the year 2000 (IBGE) as a basis, the standardized mortality coefficient for 2010 was 5.6/100.000 inhabitants, corresponding to an 11.1% reduction in the last 10 years. In 2010 the mortality coefficient by gender was 8.4/100,000 inhab. in males, and 4.2/100,000 inhab. in females (Graph 10).
In terms of the country’s regions, the mortality coefficient in 2010 was 9.4/100,000 inhabitants in the Southern Region, 7.1 in the South-East Region, 5.8 in the Northern Region, 5.4 in the Midwest Region, and 3.8 in the North-East Region. Analysis of the standardized mortality coefficient between 2000 and 2010 shows that there was an increase in AIDS mortality in the North, North-East and Southern regions, a decrease in the South-East Region and stabilization in the Midwest Region (Graph 11).
In 2010, seven of the 27 Federative Units had mortality coefficients above the national average, as follows: Amazonas (8.0/100,000 inhab.), Roraima (7.1), Rio de Janeiro (10.3), São Paulo (7.2), Santa Catarina (9.0), Rio Grande do Sul (13.6) and Mato Grosso (7.0). Between 2000 and 2010, 19 states had an increase in the standardized AIDS mortality coefficient. The biggest reduction in the AIDS mortality coefficient occurred in the state of São Paulo, from 11.3/100,000 inhabitants in 2000 to 6.4 in 2010.
Graph 10.
Graph 11.
Reducing mother-to-child transmission of HIV and syphilis is an important component of the Ministry of Health’s Health Pact (2006) on the policy regarding the prevention of maternal and infant mortality. Access to antenatal care, early diagnosis of HIV and syphilis in pregnant women, as well as to the adequate treatment of both diseases, is essential for controlling mother-to-child HIV and syphilis transmission.
Mother-to-child HIV transmission was assessed in 2004 by means of a Ministry of Health multicentre study conducted by the Brazilian Paediatrics Society. The study found an estimated mother-to-child HIV transmission rate of 6.8% in Brazil (unpublished DDAHV data). It is relevant to note that in the state of São Paulo, where antenatal health care coverage is high (97%) and antiretroviral prophylaxis for mother-to-child transmission has attained 85.5%, a mother-to-child transmission rate of 2.7% was observed in 2004 (Matida, 2010).
The 2006 Parturient Sentinel Study found HIV prevalence of 0.41%, corresponding to an estimated 12,456 HIV-positive pregnant women. Comparing estimated data with 2006 reported cases (6,137 HIV-positive), HIV surveillance in pregnant women has reached 49.3% of expected cases.
Between 2000 and June 2011, 61,789 cases of HIV infection in pregnant women were reported on the SINAN system. 26,772 (43.3%) of these cases occurred in the South-East Region, 19,625 (31.8%) in the Southern Region, 8,493 (13.7%) in the North-East Region, 3,485 (5.6%) in the Midwest Region, and 3,378 (5.5%) in the Northern Region. In 2010, there were 5,666 cases of HIV infection in pregnant women in Brazil, of which 2,136 (37.7%) occurred in the South-East Region, 1,774 (31.3%) in the Southern Region, 909 (16.0%) in the North-East Region, 499 (8.8%) in the Northern Region, and 346 (6.1%) in the Midwest Region.
In 2010 the detection rate of HIV cases among pregnant women was 2.0 cases per 1,000 live births. The only region with a detection rate above the national average was the Southern Region which had 4.8 cases/1,000 live births. The states with the highest levels of detection in 2010 were Rio Grande do Sul (7.3/1,000), Santa Catarina (5.6), Amazonas (2.4), Rio de Janeiro (2.4), Espírito Santo (2.3), Paraná (2.2) and Mato Grosso (2.2) (Graph 12).
As a rule the highest proportions of HIV-positive pregnant women are concentrated in the 20-29 age group (51.4%), in two levels of formal education – incomplete middle school education (26.9%) and complete secondary school education (12.8%) –, as well as being concentrated in the white (42.7%) and brown (37.3%) race/colour.
Graph 12.
Chapter 3 The National Response to HIV/AIDS
The Brazilian response to the AIDS epidemic follows the principles of the National Health System, i.e., health is a right of all people and a duty of the State and is subject to the principles of universality, equity and integrality. It is organized in a decentralized manner, with actions articulated between the three levels of the Federation: Union, States and Municipalities. In addition, social participation is one of the key elements for the elaboration, implementation, monitoring and evaluation of public health policies. The Brazilian response to the AIDS epidemic is also characterized by the balance between prevention, care and treatment actions and the prioritization of the public interest in relation to economic and market interests as will be shown below.
3.1 Prevention and Diagnosis
Promoting prevention and diagnosis in Brazil takes place based on intense mobilization and articulation between the three levels of health management, as described below.
Access to diagnosis
During 2010-2011 Brazil enhanced its testing strategy with the aim of scaling up diagnosis coverage in the country. In addition to being offered by the health services, the strategy is also supported through an important partnership with civil society which has collaborated intensely in mobilizing vulnerable populations. Rapid testing is now being used on a large scale and thus provides access to effective and early diagnosis by more vulnerable segments of the population, such as men who have sex with men, injecting drug users, sex workers, river bank dwellers, indigenous populations, pregnant women, low-income populations, truck drivers, precious metal prospectors and people deprived of liberty. In addition there have been increased efforts to diagnose coinfections, such as tuberculosis, which have great impact on the morbidity and mortality of patients with AIDS.
Prevention
The actions undertaken include making available the necessary prevention commodities, with emphasis on the free of charge distribution of male and female condoms and lubricant gel by the health services and civil society partner organizations. In 2010 (and in previous years), the country took the decision to request PAHO and UNFPA intermediation
with the purchase of 20 million female condoms, in order to overcome the monopolistic contexts relating to the production and commercial representation of female condoms which prevented them from being purchased at fair prices. During the period 2010-2012, the Federal Government purchased 893 million male condoms, as per the following graph. Of these, 100 million were produced in Brazil at a government owned plant, with latex correctly extracted from the Amazon Region.
During 2010-2011 plans to fight the epidemic among specific populations continued to be implemented. These are: the National Plan to Fight the AIDS Epidemic and STDs among Gay Men, other MSM and Transvestites, and the Integrated Plan to Fight the Feminization of the STD and AIDS Epidemic.
With regard to adolescents and young adults, the partnership between the Ministry of Health and the Ministry of Education via the Health and Prevention in Schools project continues to be a reference for health and STD/AIDS actions in the school environment. During the period in question training courses were held for multidisciplinary teams in the States and Municipalities, in addition to involving the National Network of Young People Living with HIV and AIDS. Even though this initiative involves several partnering institutions at federal, state and municipal levels, there is always a risk of changes in some teams due to local political arrangements, constituting a challenge to the continuity of planned activities.
In relation to universal access to diagnosis, Brazil has adopted the following strategies:
• Decentralization of testing actions;
• Structuring of laboratory networks for the purposes of patient testing and monitoring;
• Political incentives for testing;
• Social mobilization to encourage the population to seek early diagnosis;
• Preparation of national norms and protocols;
• Articulation with organized civil society;
• Guaranteeing financial resources through agreements with the different service management levels for the purchase of tests for diagnosis;
• Increased funding for specific commitments, such as the reduction of mother-to-child transmission.
Indigenous populations
Following the increase in the number of AIDS cases among the country’s indigenous population, as per data recorded on the SINAN system in the last decade, an Action Plan for HIV/AIDS and STD Interventions in Indigenous Communities has been prepared and implemented in collaboration with the Special Secretariat for Indian Health of the Ministry of Health (SESAI). These actions involve three strategic areas: enhancing the surveillance system, scaling up diagnosis and reducing mother-to-child transmission. It should be noted that most part of this population inhabits isolated, hard to access, areas of the Brazilian territory and there is a need of knowledge of their costumes, languages and beliefs, making it much harder to implement prevention strategies.
Armed Forces
By means of a partnership between the Ministry of Health, the Ministry of Defence and UNAIDS, STD/AIDS prevention and control actions are undertaken with the members of the country’s Armed Forces, with emphasis on the young (recruits and students at Military Colleges and Training Centres) and Peace Mission personnel, including those on active service and the demobilized. The actions consist of training peer educators and holding informative and mobilizing lectures.
Since the Programme’s activities began in 2004, 37 Peer Educator Training Courses have been held and 1,267 educators have been trained, distributed as follows: 307 from the
Navy, 679 from the Army and 281 from the Air Force. Every year the educators undertake prevention actions with 125,000 young military personnel (recruits and students) and 5,028 military personnel deployed in UN peacekeeping forces.
Prevention in the workplace
Following the approval in 2010 of ILO Recommendation 200 on HIV and the world of work, the Ministry of Health in partnership with the Ministry of Labour, ILO, trade unions and the National Business Council on HIV/AIDS Prevention have started publicizing and implementing the Recommendation in the country.
During 2010-2011, the Department of STD, AIDS and Viral Hepatitis and the São Paulo State and Municipal STD/AIDS Programmes, in partnership with trade unions, ILO, the Ministry of Labour and the CSA, gave courses for workers with the aim of training STD/HIV/AIDS prevention agents in the workplace, in accordance with ILO “Recommendation 200”. The first Module of the “Train the Trainers Course on HIV/AIDS in the Workplace” took place on December 8-10 2010 and 50 workers were trained. The second Module was held in São Paulo on August 15-17 and 35 workers were trained.
Prevention among drug users
In 2011, the Brazilian President Dilma Rousseff launched the “Plan for the confrontation of the use of crack and other drugs”. This programme, with an investment of U$ 2 billion, has among its objectives to provide adequate care to drug dependent individuals and their families, to tackle drug trafficking and to prevent the use of addictive substances. The Ministry of Health will qualify professionals and establish specialized wards in public hospitals in Brazil´s main cities, and also the creation of “street outpatient clinics”.
3.2 STD and AIDS care and treatment
Access to treatment
The Brazilian Government has guaranteed universal and free of cost access to antiretroviral treatment since 1996. The antiretroviral drugs are purchased by the Ministry of Health and distributed exclusively via the public health system Medication Dispensing Units (MDU), also meeting the needs of private health service patients. Drugs for the treatment of opportunistic infections and other STDs are purchased by the state-level governments, in accordance with agreements between the three levels of government that form the NHS. The
Ministry of Health has various committees that advise the Department of STD, AIDS and Viral Hepatitis on procedural norms in relation to antiretroviral therapy for HIV-positive adults, children and adolescents and pregnant women.
In 2010 some 200,000 people received antiretroviral treatment on the NHS via 737 Specialized Care Service units located in municipal or state polyclinics, reference hospitals, primary healthcare centres, STD clinics, specialized STD/AIDS outpatient services, etc. The care network also includes 707 Medication Dispensing Units, 418 hospitals accredited to treat AIDS, 92 day hospitals and 91 home care units, totalling 1,556 services.
The range of antiretroviral drugs available in Brazil is comprised of 19 active ingredients and one fixed-dose combination which are available in 38 pharmaceutical formulations for adult and paediatric use (Table 3). Ten antiretroviral drugs are currently produced in Brazil by several public laboratories and one private laboratory.
Table 3. ANTIRETROVIRAL DRUGS (Brazil, 2012)
TYPE OF PRODUCTION
NATIONAL IMPORTED
Didanosine (ddI) 4g powder for oral solution Abacavir (ABC) 300mg
Efavirenz (EFZ) 600mg Abacavir (ABC) 20mg/ml oral solution
Stavudine (d4T) 30mg Atazanavir (ATV) 200mg
Stavudine (d4T) 1mg/ml powder for oral
solution Atazanavir (ATV) 300mg
Indinavir (IDV) 400mg Darunavir (DRV) 75mg
Lamivudine (3TC) 150mg Darunavir (DRV) 150mg
Lamivudine (3TC) 10mg/ml oral solution Darunavir (DRV) 300mg Nevirapine (NVP) 200mg Didanosine (ddI) EC 250mg Saquinavir (SQV) 200ml Didanosine (ddI) EC 400mg Tenofovir (TDF) 300 mg Efavirenz (EFZ) 200mg
Zidovudine (AZT) 100mg Efavirenz (EFZ) 30mg/ml oral solution Zidovudine (AZT) 10mg/ml injection solution Enfuvirtide (T-20)
Zidovudine (AZT) 10mg/ml oral solution Etravirine 100mg
Fosamprenavir (FPV) 700mg Zidovudine (AZT) 300mg + Lamivudine (3TC)
150mg (fixed-dose combination) Fosamprenavir (FPV) 50mg/ml oral solution Lopinavir/Ritonavir (LPV/r) 100/25mg Lopinavir/Ritonavir (LPV/r) 200/50mg Lopinavir/Ritonavir (LPV/r) 80/20mg/ml oral solution
Nevirapine (NVP) 50mg/5ml oral suspension Raltegravir 400mg
Ritonavir (RTV) 100mg
Ritonavir 80mg/ml oral solution Tipranavir 250 mg
Tipranavir 100mg/ml oral solution Source: DDAHV
Antiretroviral drug dispensing has been managed by the Medication Logistics Control System (Sistema de Controle Logístico de Medicamentos - SICLOM) since 1997. Apart from controlling the distribution, dispensing and stock levels, the system assists the analysis of the medical prescriptions in accordance with Ministry of Health technical recommendations. The National Network of Genotyping Laboratories (Rede Nacional de Laboratórios de Genotipagem - RENAGENO) was created in 2002 and helps doctors to choose the best treatment regimen. If a doctor prescribes third-line drugs, such as Indinavir or Stavudine, the Technical Committees in the states analyse the case and emit a report either favourable or contrary to the drug being indicated.
In 2009 the Department introduced tools for analysing the impact on public health, economic evaluation and evidence-based practices, with the aim of establishing more precise parameters to estimate the impact of changes in treatment strategies, as well as the incorporation of new interventions and medications into the range available, thereby strengthening the sustainability of universal access to treatment. In the same year Raltegravir (integrase inhibitor) was incorporated into the treatment recommendations, followed in 2010 by Etravirine (second generation non-nucleoside reverse transcriptase inhibitor) and Tipranavir (protease inhibitor) for exclusive use in children and adolescents in 2011. All these drugs are part of third-line treatment.
According to a survey done in December 2008 as to the Brazilian treatment recommendations, approximately 83.2% of patients on ARVT were using first-line drugs, including protease inhibitor alternatives, 13.5% were using second-line drugs and 3.3% were using third-line drugs. The regimen recommended as the first treatment option, comprised of Efavirenz, Lamivudine and Zidovudine (EFZ+3TC+AZT), was being used by 47.8% of these patients.
Coinfections
HIV/TB coinfection is estimated as being 8.8% and tuberculosis is currently the principal cause of death among patients with AIDS – the death rate is as much as 20%.
Joint actions undertaken by the DDAHV and the National Tuberculosis Control Programme are being scaled up. They include: the implementation of tuberculin testing in the Specialized Care Service units and Isoniazid chemoprophylaxis for patients with PPD ≥ 5 mm, radiologic scarring or a history of contact with TB bacillus carriers, after active infection has been discarded; scaling-up access to early diagnosis of HIV infection in people with
tuberculosis. Also, it is important to acknowledge the significant contribution of the Global Fund (Global Fund Programme TB/Brazil) where social mobilization actions contributed to raise awareness in relation to the risks of TB infection among PLWHA.
Viral hepatitis coinfections, principally hepatitis B and C, also have great magnitude and impact on AIDS mortality. Hepatitis C coinfection has high prevalence among patients with AIDS and can be as high as 54%. The National Viral Hepatitis Programme has been integrated into the Department of STD and AIDS since November 2009, with the aim of optimizing the prevention, diagnosis and treatment actions related to these diseases.
National Guidelines
All the complex issues of patient management are guided by clinical protocols prepared by expert committees and based on available scientific evidence. The treatment recommendations are widely publicized among medical professionals through seminars, workshops and, recently, also by distance learning courses, with the aim of broadening their reach. Recent studies indicate that the medical professionals are using the National Guidelines on Antiretroviral Treatment in their daily practice.
The recommendations are updated annually. The criteria for starting treatment have been revised recently, so that starting ARVT is now recommended for patients with lymphocyte counts of CD4 < 350 cells/mm³ and should be considered for those with CD4 lymphocyte counts between 350 and 500 cells/mm³. The committees also advise on decisions as to the incorporation of new antiretroviral drugs by the NHS. This indication is assessed by the National Commission on Technology Incorporation (CONITEC) which, if approved, recommends its incorporation to the Ministry of Health. In this way, Darunavir was incorporated in 2008, Raltegravir in 2009 and Tipranavir for children and Etravirine in 2010.
The incorporation of third-line ARVs enables the adequate and effective rescue of multiresistent patients, resulting in their increased survival time and improved quality of life.
With regard to the guarantee of the reproductive rights of people living with HIV and AIDS, Brazil has established recommendations to minimize the risk of HIV transmission between seroconcordant or serodiscordant couples who want to have children with greater safety and in different situations.
Adherence
Treatment adherence is extremely important for the durability of the established treatment regimen. A very positive statistic that can be related to adherence is that data
available on 166,000 patients on treatment showed that 78% had viral load counts below 1,000 copies and 67% of these had undetectable viral load.
In 2008 a study was conducted with focal groups of patients using STD/AIDS outpatient services. The results relating to issues such as service organization, multidisciplinary teams, opening hours, are being used to improve the service provided to these patients with the aim of improving treatment adherence, among others. In 2009 a series of videos was produced for use in the waiting rooms of the specialized services, with the aim of providing information and guidance, as well as encouraging patients to share experiences. In 2010 and 2011 informative materials were also produced based on the results of the focal groups.
Lipodystrophy
Lipodystrophy can be the cause of interrupted or abandoned treatment, as a result of low self-esteem or even states of depression caused by the physical alterations it can produce.
Treating lipodystrophy is, therefore, one of the biggest challenges to the quality of life of people living with HIV/AIDS (PLWHA).
A Ministerial Ordinance was published in 2009 establishing the criteria for the accreditation of hospitals and services providing surgery and outpatient treatment for this adverse effect, as well as defining that the following reparative procedures can be performed on the NHS: facial filling using polymethylmethacrylate (PMMA), liposuction of the lower jaw region, the back of the neck and shoulders or the abdominal wall, breast surgery or gynaecomastia and surgical treatment of buttock lipoatrophy by means of implanting prostheses.
Ten hospitals are currently accredited and qualified to perform reparative surgery and facial filling, as well as a further thirteen outpatient services authorized to perform facial filling to treat facial lipoatrophy. Between 2005 and 2010, 222 dermatologists and plastic surgeons from most of the Brazilian states were trained and more than 9,500 facial fillings using PMMA were performed during the period. In 2009 and 2010 some 120 reparative operations were performed in the accredited hospitals.
Prevention of mother-to-child HIV and syphilis transmission
The strategies for preventing the mother-to-child transmission of HIV and syphilis implemented by the Brazilian Government include the holding of informative campaigns, training courses, the scaling up of the specialized network and the provision of prevention
commodities, such as rapid HIV tests, tests for syphilis, antiretroviral medication (for parturient women and exposed children), lactation inhibitors (Cabergoline) and infant formula. All these commodities are provided by the NHS.
The strategies adopted have contributed substantially to the reduction of AIDS cases in children aged under 5 (the incidence rate, which was 5.9/100,000 inhabitants in 1998, dropped to 3.5/100,000 inhabitants in 2010). Even so there are still currently many challenges to be overcome.
In 2010 a project was implanted in partnership with UNICEF to enhance the mother-to- child transmission healthcare services in the Brazilian Amazon and in North-East Brazilian states, with the aim of scaling up the coverage of HIV and syphilis diagnosis in primary healthcare and antenatal services for infected pregnant women and children exposed to HIV.
The “Stork Network” initiative was established by the Ministry of Health in 2011, with the objective of guaranteeing to all Brazilian women, through the Public Health System (SUS), adequate and safe care, from the beginning of pregnancy through all the antenatal period and delivery, and in the first two years of the new-born. The “Stork Network” will receive U$ 4.5 billion from the Ministry of Health budget for investments through 2014. All PMTCT strategies are integrated into the “Stork Network”.
3.3 Human Rights
The Brazilian response to the AIDS epidemic is based on the principle that health is a right of all people and on total respect for human rights. This commitment is reflected in its institutional structure. Since the year 2000 the Department of STD, AIDS and Viral Hepatitis has specific sectors to foster articulation with civil society and promote the human rights of people living with HIV/AIDS and more vulnerable populations. States and municipalities also work on this issue.
The initiatives undertaken as part of the Brazilian response have always been based on guaranteeing the rights of vulnerable populations, in particular the right to confidentiality, non-discrimination and equal access to health services. The Ministry of Health considers that AIDS is a disease associated with inequality and not just with poverty – it is inequality that increases the vulnerability of poor populations – e.g. gender inequality, inequality in relation to sexual orientation and racial inequality. Specific actions have been developed aimed at
eliminating possible obstacles to universal access by vulnerable populations, such as gay men, lesbians, transvestites and transsexuals, sex workers and drug users.
Actions to combat stigma and discrimination include campaigns, supporting civil society organizations in providing legal aid, supporting social mobilization actions, such as events and meetings in which social movement articulation occurs.
3.4 International Cooperation
The Brazilian policy sees public health as a fundamental element for the social and economic development of countries. As such Brazil is committed to providing aid and knowledge sharing with other countries with the aim of promoting the health of all people, especially through actions that improve access to medication and prevention commodities in an equitable and sustainable manner, in addition to promoting human rights in addressing the HIV/AIDS epidemic.
In international negotiations Brazil has always defended the need to guarantee universal access to treatment and to prevention commodities and other human rights relating to the fight against the epidemic, the adoption of measures that enable greater flexibilization of the current intellectual property system, as well as the institutional strengthening of national health systems and South-South cooperation.
The Brazilian experience in responding to the HIV/AIDS epidemic has contributed to progress in addressing the AIDS epidemic in other developing countries, especially in Latin America, the Caribbean and Africa. This collaboration takes place through the sharing of Brazilian experiences by means of technical cooperation projects and other partnerships with countries and international organizations.
In order to achieve this aim, the Ministry of Health works together with the Ministry of External Relations, through the Brazilian Cooperation Agency and other Ministries, in addition to other Brazilian governmental and non-governmental institutions. It also works very closely with United Nations organizations – such as UNAIDS, PAHO/WHO, UNESCO, UNICEF, UNODC, ILO, UNFPA and UNIFEM – and bilateral cooperation agencies.
